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<br />CERTIFICATE OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold <br />the issuance or renewal of a license or permit to operate a business or engage in an activity in <br />Minnesota until the applicant presents acceptable evidence of compliance with the workers' <br />compensation insurance coverage requirements ofMSS Chapter 176. The information required <br />is: the name of the insurance company, the policy number, and dates of coverage, or the permit <br />to self-insure. This information will be collected by the City and retained in the files. <br /> <br />This information is required by law, and licenses and permits to operate a business may not be <br />issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this <br />information is not provided or falsely stated, it may result in a $1,000 penalty assessed against <br />the applicant by the Commissioner of the Department of Labor and Industry. <br /> <br />Insurance Company Name: <br />(NOT the insurance agent) <br /> <br />Policy Number: <br /> <br />Dates of Coverage: <br /> <br />TO <br /> <br />(OR) <br /> <br />I am not required to have workers' compensation liability coverage because: <br /> <br />o I have no employees <br /> <br />D I am self-insured (include permit to self-insure) <br /> <br />D I have no employees who are covered by the workers' compensation law <br />(these include: spouse, parents, children and certain farm employees) <br /> <br />I certifY that the information pr~te and complete and that a valid <br />workers' compensation policy w~all times as required by law. <br /> <br />Name: /1t ,,"~Ii-i.l 'I/t'DIVIAS <br />[First ] [Middle] <br /> <br />Name of Business: ('f-Ilreli. vILIA;- l-t 'flit){"> <br /> <br />t1,I.q.["M"""- <br />[Last] <br /> <br />Business Address: <br /> <br />7013 2-0 p, Ave S: <br /> <br />(enre-r.Vi t-t.(! <br />[City] <br /> <br />;111\1 <br />[State] <br /> <br />S"S()]& <br />[Zip] <br /> <br />Business Phone: <br /> <br />651 <br /> <br />LiZ,6 - 66 1<1 <br />~ -;f{ W~ <br />Signature <br /> <br />'2-- -- 2--2_" 1- <br />Date <br />